Welcome to The Campbell Group

January 7, 2009

Please note that the results of this form will be sent via email. In the unlikely event that you encounter problems, please print your form and fax it to 800-847-3129.
GENERAL INFO	* Required Field
First Name:	*
Middle Name:	*
Last Name:	*
Address:	*
City:	*
State:	*
Zip:	*
Home Phone:	*
Work Phone:	Extension
Fax:
Email Address:
# of Drivers:	*
# of Vehicles:	*
Best Time To Call:	AM PM
Where do you access the Internet?
I prefer to be contacted at:
Are you currently insured?	Yes No
If Yes, who is your current insurance carrier?
When does your current policy expire?	(mm/dd/yyyy)

DRIVER INFO
Driver Name:
Age:
Gender:	Male Female
Marital Status	Single Married Widowed
Occupation:
License #:
Licensed in State:
Social Security #:
Driver Training:
Student more than 100 miles away at school?	Yes No *
Has driver ever had a license suspended or revoked?	Yes No *
Does any driver require a Financial Responsibility Statement (also known as SR-22)? This is a requirement that the State be notified if a driver cancels their insurance. If you are 100% certain of the answer, please select one of the following:	Yes No

DRIVER INFO
Year:	(please show 4-digit year)*
Make:	*
Model:	*
Body Style:	*
Check all that apply:	4-Wheel Drive Alarm Airbag
Vehicle Identification (VIN) #:	*

COVERAGES REQUESTED
If you are unsure of the limits that you need on your policy, please leave this section blank and our customer service staff will be happy to advise you.
Bodily Injury Liability:	$
Property Damage Liability:	$
Uninsured Motorist Bodily Injury Liability:	$
Underinsured Motorist Bodily Injury Liability:	$
PIP � Medical Expense:	$
PIP � Loss of Income:	$
PIP � Accidental Death:	$
PIP � Funeral Expense Benefits:	$
Extraordinary Medical Benefits:	$
Comprehensive Deductible:	$
Collision Deductible:	$
Rental Reimbursement:	$
Towing & Labor:	$
Additional coverage(s) requested:
Comments and questions:



IMPORTANT: This information is requested for the sole purpose of creating your insurance profile. From this profile, we will generate insurance quotes by using the rating methods. When you submit this form, the information will be transmitted via email to our customer service department. If you are not comfortable in send this information through email and the Internet, we suggest that you print the completed form and fax it to us at 800-847-3129. DISCLAIMER: By submitting this application to The Campbell Group, I hereby declare that the above statements are true. No coverage will be issued or bound until I receive confirmation from a licensed representative of The Campbell Group. I understand that this is a request for a quotation only and that I am under no obligation.

Please note that the results of this form will be sent via email.
In the unlikely event that you encounter problems, please print your form and fax it to 800-847-3129.